The XX Factor

Paying Low-Income Moms to Breastfeed Might Raise Breastfeeding Rates, But Is It Ethical?

Before we start paying moms to breastfeed, we should be making sure they can afford to take time off after childbirth.

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The benefits of breastfeeding are often exaggerated, but everyone can agree that women should have the resources to breastfeed their infants if they so choose. Unfortunately, many women don’t have those resources, which is part of the reason that low-income women are far less likely to breastfeed than their wealthier counterparts. (Cultural norms also play a role.) Public health advocates are constantly seeking new ways to boost breastfeeding rates among this population and have implemented a variety of educational and support programs in order to do so.

One of the largest efforts to get more low-income women to breastfeed is part of the Women, Infants, and Children Program. This federal nutrition assistance program, which serves around 8 million moms and young children, incentivizes breastfeeding by offering those who do it “a greater quantity and variety of foods” and “longer participation in the program.” Now a new study, recently published in Pediatrics, explores what would happen if WIC upped the ante and gave breastfeeding moms a cash bonus as well. The study’s authors found that this extra compensation was effective in raising breastfeeding rates, but questions about the ethics of cash incentives remain.

For the study, a team of researchers, led by Dr. Yukiko Washio of Christiana Care Health System and the University of Delaware in Newark, divided 36 low-income, Puerto Rican new mothers enrolled in WIC into two groups. Half of them would receive cash incentives to breastfeed totaling up to $270 over the course of six months; the other half would not. At one month, 89 percent of women who were being paid were still breastfeeding, compared with 44 percent of mothers who were not being paid. At three months, the percentage of the cash group who were still breastfeeding remained the same, while the control group’s breastfeeding rates declined to 17 percent. When the babies were six months old, 72 percent of the mothers receiving payments were still breastfeeding, while none of the mothers in control group were.

The study’s authors offer a few caveats about the results. First, the sample size was too small to draw any big conclusions, and the program should be tested with a larger group of women before any large-scale program is implemented. And the health effects of the incentives were unclear—the study found was no significant difference in emergency room visits between the two groups. However, the authors predict that a rise in breastfeeding stemming from cash incentives would lead to better health outcomes for infants, which could save $17 million in healthcare costs and allow WIC to spend more of its budget on food rather than formula. (Formula is currently the most expensive line-item in the program’s budget.) Future studies should carefully track infants’ health outcomes to ensure that they are benefiting from breastmilk. Lastly and importantly, the authors acknowledge that more research should be done on the psychological effects the cash incentives have on the mothers who receive them. What’s effective isn’t always benign, especially when money is involved.

In an accompanying editorial in Pediatrics, Dr. Lydia Furman of Case Western Reserve University and Rainbow Babies and Children’s Hospital in Cleveland, Ohio questions whether these payments end up coercing low-income women into breastfeeding, including those who would otherwise have chosen not to. However, she ultimately concludes that such interventions can be “ethically defensible and socially responsible” if they manage to “level the playing field” for low-income women.

A small part of me loves the idea of women given cash for breastfeeding. It deromanticizes the act, stripping it of its associations with beauty and instinct and acknowledging what it is for most women: hard work. But a bigger part of me sees red flags. Would a cash incentive program make the notoriously frustrating and prescriptive WIC even more stressful for low-income mothers? Would it encourage other adult household members to pressure moms to breastfeed? Also, would it push moms to prioritize providing their children with breastmilk, whether by way of boob or pump, above all other aspects of infant care? I know and have read about many women for whom the pressure to breastfeed was so stressful that it interfered with their ability to bond with their babies.

Breastfeeding is a huge commitment and can be extremely taxing, particularly if a woman works shortly after childbirth or has other young children to take care of. Incentives like the ones offered in the study might work for some women in some scenarios, but I am not sure they make sense for most low-income American women considering everything else they are up against. In a country where so many go without paid leave and affordable childcare, giving breastfeeding women a little pocket money for their efforts feels more like a shortsighted stopgap than a promising longterm solution.